This comment jointly authored by Beverley Chalmers (DSc(Med); PhD)and Janusz Kaczorowski, (PhD).
It is gratifying to see a publication emerging utilizing the data collected by the Maternity Experiences Survey. This major research program was conducted by the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System of the Public Health Agency of Canada in collaboration with Statistics Canada.
It is disappointing, however, to note the errors and omissions that this particular manuscript includes. The issue of predicting exclusive breastfeeding at 6 months after birth is an extremely important one for both mothers and babies globally and in Canada. For this reason, some clarification of this BMC Pediatrics report is needed. These include:
1 The authors have not given full and appropriate credit to the original Maternity Experiences Study. They report: “The analysis of this study was based on the Maternity Experiences Survey (MES) that was sponsored by [the] Public Health Agency of Canada and conducted by Statistics Canada in 2006” As clearly stated in the MES report (PHAC 2009)(which the authors omit to reference) the Maternity Experiences Study Group (MESG) of the Canadian Perinatal Surveillance System (CPSS) guided all phases of the MES including the development of the questionnaire and sampling methods, pilot testing, interviewer training, data collection and processing, and data analysis and reporting. The PHAC-StatCan Project team, guided by the PHAC-StatCan Project Steering Committee and the MESG was responsible for the day-to-day implementation of the survey.
2 The authors do, however, give thanks “to the MESG of the CPSS of PHAC and the staff of the Toronto Region-Statistics Canada Research Data Centre …. for their valuable help and support.” This acknowledgment, by juxtaposition of the two agencies, implies that the MESG of the CPSS of the PHAC offered valuable help and support for this publication. The MESG of the CPSS and PHAC were, however, not involved in any way with the preparation of this publication.
3 The authors do not reference the major publications of the Maternity Experiences Survey that refer specifically to breastfeeding. These include the full PHAC report on the data entitled: “What Mothers Say: The Canadian Maternity Experiences Survey” (PHAC, 2009) and an article “Breastfeeding Rates and Hospital Breastfeeding Practices in Canada: A National Survey of Women” (Chalmers et al, 2009). As the current publication is based on this data this omission is surprising.
4 The authors report that “WHO advocates for breastfeeding as the best source of food for optimal infant growth and development”. While this is true, the collaboration of UNICEF in all statements regarding the promotion and support of breastfeeding globally is not acknowledged. All breastfeeding statements promoting breastfeeding practices published by the UN have been joint statements of both WHO and UNICEF. Nor are the primary documents protecting and promoting breastfeeding by these two agencies acknowledged in this publication (WHO/UNICEF 1989a, 1989b, 1990). Instead two articles are provided as supporting WHO’s statement: the first a systematic review of the optimal duration of exclusive breastfeeding by Kramer et al (2004)(which while an excellent document is not a WHO or UNICEF publication or statement) and the second an on-line Q and A paragraph regarding the optimal duration of breastfeeding on a WHO website. One would think that a more comprehensive and accurate report of the fundamental concept being explored in this paper would have been undertaken and reported by the authors.
5 The authors refer to only one previous nationwide study of the prevalence and predictors of breastfeeding across Canadian provinces (Miller and Maclean 2005). They ignore both the repeated reports of the National Longitudinal Surveys of Children and Youth conducted every few years by Statistics Canada and the Perinatal Health Reports also published regularly every few years by the Public Health Agency of Canada, both of which contain substantial data regarding breastfeeding prevalence and duration across the provinces of Canada.
6 Most surprising of all, however, is the lack of mention of the WHO/UNICEF Baby Friendly Hospital Initiative with its Ten Steps to successful breastfeeding, eight of which (all those referring to mothers rather than to hospital practices) were explored in the Maternity Experiences Survey. Not only is this not mentioned in the current report, but the variables included in the MES that evaluated the Canadian provinces and territories adherence to the steps that are regarded as essential to successful breastfeeding were not even included in the predictive analysis conducted in this report. It is somewhat incomprehensible to think of attempting to predict exclusive breastfeeding at 6 months without exploring the role played by these known contributory factors to successful breastfeeding – especially when the data was available to the researchers. These omitted variables include for example, providing information for mothers regarding breast or formula feeding, timing of first contact between mother and baby, timing of first breast feed, separation of mother and baby after birth (excluding NICU care), skin-to-skin contact after birth, rooming-in, assistance given with first breastfeeds, demand or schedule feeding, providing breastmilk substitutes to mothers in hospital, use of pacifiers, and others.
7 The importance of home delivery is overstated — there were very few women who home-delivered — this is further underscored by very wide confidence intervals for that variable (Odds Ratio: 5.29, 95%, Confidence Interval: 2.95-9.46). Furthermore, in discussion the authors state the following: ‘In the present study, the place of delivery was associated with the 6 month duration of exclusive breastfeeding. Mothers giving birth at home were 5 times more likely to exclusively breastfeed than mothers giving birth at hospitals. This relationship can be attributed to the negative influence of formula supplementation in the hospital [9]. Given that formula supplementation in hospital is not even included in the analyses of this study, and that numerous factors contribute to the duration of exclusive breastfeeding, including at the very least the variables noted by the BFHI, this conclusion is hardly justified.
8 Finally, it is a pity that the authors chose to omit any real analysis of obstetric practices in predicting breastfeeding outcomes. While place of birth (home versus hospital) and type of delivery (vaginal versus caesarean) were explored, none of the remaining variables relating to care during labour and postpartum were included in the univariate or predictive analyses. Issues such as induction or augmentation of labour, epidural use, pain medication in labour, assisted delivery, episiotomy, and others – all of which are available in the MES - are not included despite their possible role in breastfeeding initiation and duration.
While we applaud the attempt to examine this important issue, we just wish the study would have been implemented more carefully and thoroughly.
Beverley Chalmers (DSc(Med); PhD) Co-Chair, Maternity Experiences Study Group, 1999-2009 Adj Prof, Dept of Obstetrics and Gynaecology Affiliate Investigator, Ontario Health Research Institute University of Ottawa Ottawa, Canada
Janusz Kaczorowski, (PhD) Maternity Experiences Study Group Member, 1999-2009 Dept of Family Practice, University of British Columbia Director, Community and Primary Care Research Child and Family Research Institute Vancouver, British Columbia, Canada
References 1. Chalmers B, Levitt C, Heaman M, O’Brien B, Sauve R, Kaczorowski J and the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System. Breastfeeding Rates and Hospital Breastfeeding Practices in Canada: A National Survey of Women. Birth. 2009, 36(2), 122-132. 2. Public Health Agency of Canada. What Women Say: The Maternity Experiences Survey of the Canadian Perinatal Surveillance System. Public Health Agency of Canada Report, 2009. 3. World Health Organization/UNICEF Protecting, Promoting and Supporting Breastfeeding: The special role of maternity services. A joint WHO/UNICEF Statement. Geneva: World Health Organization, 1989a. 4. World Health Organization/UNICEF. Ten Steps to Successful Breastfeeding. Geneva: Author, 1989b. 5. World Health Organization/UNICEF. Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. Breastfeeding in the 1990’s: Global initiative. WHO/UNICEF sponsored meeting, Florence, Italy, 1990.
Competing interests
Beverley Chalmers and Janusz Kaczorowski were both members of the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System. Beverley Chalmers was the Co-Chair of this group.
A Disapponting Study
17 June 2010
This comment jointly authored by Beverley Chalmers (DSc(Med); PhD)and Janusz Kaczorowski, (PhD).
It is gratifying to see a publication emerging utilizing the data collected by the Maternity Experiences Survey. This major research program was conducted by the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System of the Public Health Agency of Canada in collaboration with Statistics Canada.
It is disappointing, however, to note the errors and omissions that this particular manuscript includes. The issue of predicting exclusive breastfeeding at 6 months after birth is an extremely important one for both mothers and babies globally and in Canada. For this reason, some clarification of this BMC Pediatrics report is needed. These include:
1 The authors have not given full and appropriate credit to the original Maternity Experiences Study. They report: “The analysis of this study was based on the Maternity Experiences Survey (MES) that was sponsored by [the] Public Health Agency of Canada and conducted by Statistics Canada in 2006” As clearly stated in the MES report (PHAC 2009)(which the authors omit to reference) the Maternity Experiences Study Group (MESG) of the Canadian Perinatal Surveillance System (CPSS) guided all phases of the MES including the development of the questionnaire and sampling methods, pilot testing, interviewer training, data collection and processing, and data analysis and reporting. The PHAC-StatCan Project team, guided by the PHAC-StatCan Project Steering Committee and the MESG was responsible for the day-to-day implementation of the survey.
2 The authors do, however, give thanks “to the MESG of the CPSS of PHAC and the staff of the Toronto Region-Statistics Canada Research Data Centre …. for their valuable help and support.” This acknowledgment, by juxtaposition of the two agencies, implies that the MESG of the CPSS of the PHAC offered valuable help and support for this publication. The MESG of the CPSS and PHAC were, however, not involved in any way with the preparation of this publication.
3 The authors do not reference the major publications of the Maternity Experiences Survey that refer specifically to breastfeeding. These include the full PHAC report on the data entitled: “What Mothers Say: The Canadian Maternity Experiences Survey” (PHAC, 2009) and an article “Breastfeeding Rates and Hospital Breastfeeding Practices in Canada: A National Survey of Women” (Chalmers et al, 2009). As the current publication is based on this data this omission is surprising.
4 The authors report that “WHO advocates for breastfeeding as the best source of food for optimal infant growth and development”. While this is true, the collaboration of UNICEF in all statements regarding the promotion and support of breastfeeding globally is not acknowledged. All breastfeeding statements promoting breastfeeding practices published by the UN have been joint statements of both WHO and UNICEF. Nor are the primary documents protecting and promoting breastfeeding by these two agencies acknowledged in this publication (WHO/UNICEF 1989a, 1989b, 1990). Instead two articles are provided as supporting WHO’s statement: the first a systematic review of the optimal duration of exclusive breastfeeding by Kramer et al (2004)(which while an excellent document is not a WHO or UNICEF publication or statement) and the second an on-line Q and A paragraph regarding the optimal duration of breastfeeding on a WHO website. One would think that a more comprehensive and accurate report of the fundamental concept being explored in this paper would have been undertaken and reported by the authors.
5 The authors refer to only one previous nationwide study of the prevalence and predictors of breastfeeding across Canadian provinces (Miller and Maclean 2005). They ignore both the repeated reports of the National Longitudinal Surveys of Children and Youth conducted every few years by Statistics Canada and the Perinatal Health Reports also published regularly every few years by the Public Health Agency of Canada, both of which contain substantial data regarding breastfeeding prevalence and duration across the provinces of Canada.
6 Most surprising of all, however, is the lack of mention of the WHO/UNICEF Baby Friendly Hospital Initiative with its Ten Steps to successful breastfeeding, eight of which (all those referring to mothers rather than to hospital practices) were explored in the Maternity Experiences Survey. Not only is this not mentioned in the current report, but the variables included in the MES that evaluated the Canadian provinces and territories adherence to the steps that are regarded as essential to successful breastfeeding were not even included in the predictive analysis conducted in this report. It is somewhat incomprehensible to think of attempting to predict exclusive breastfeeding at 6 months without exploring the role played by these known contributory factors to successful breastfeeding – especially when the data was available to the researchers. These omitted variables include for example, providing information for mothers regarding breast or formula feeding, timing of first contact between mother and baby, timing of first breast feed, separation of mother and baby after birth (excluding NICU care), skin-to-skin contact after birth, rooming-in, assistance given with first breastfeeds, demand or schedule feeding, providing breastmilk substitutes to mothers in hospital, use of pacifiers, and others.
7 The importance of home delivery is overstated — there were very few women who home-delivered — this is further underscored by very wide confidence intervals for that variable (Odds Ratio: 5.29, 95%, Confidence Interval: 2.95-9.46). Furthermore, in discussion the authors state the following: ‘In the present study, the place of delivery was associated with the 6 month duration of exclusive breastfeeding. Mothers giving birth at home were 5 times more likely to exclusively breastfeed than mothers giving birth at hospitals. This relationship can be attributed to the negative influence of formula supplementation in the hospital [9]. Given that formula supplementation in hospital is not even included in the analyses of this study, and that numerous factors contribute to the duration of exclusive breastfeeding, including at the very least the variables noted by the BFHI, this conclusion is hardly justified.
8 Finally, it is a pity that the authors chose to omit any real analysis of obstetric practices in predicting breastfeeding outcomes. While place of birth (home versus hospital) and type of delivery (vaginal versus caesarean) were explored, none of the remaining variables relating to care during labour and postpartum were included in the univariate or predictive analyses. Issues such as induction or augmentation of labour, epidural use, pain medication in labour, assisted delivery, episiotomy, and others – all of which are available in the MES - are not included despite their possible role in breastfeeding initiation and duration.
While we applaud the attempt to examine this important issue, we just wish the study would have been implemented more carefully and thoroughly.
Beverley Chalmers (DSc(Med); PhD)
Co-Chair, Maternity Experiences Study Group, 1999-2009
Adj Prof, Dept of Obstetrics and Gynaecology
Affiliate Investigator, Ontario Health Research Institute
University of Ottawa
Ottawa, Canada
Janusz Kaczorowski, (PhD)
Maternity Experiences Study Group Member, 1999-2009
Dept of Family Practice, University of British Columbia
Director, Community and Primary Care Research
Child and Family Research Institute
Vancouver, British Columbia, Canada
References
1. Chalmers B, Levitt C, Heaman M, O’Brien B, Sauve R, Kaczorowski J and the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System. Breastfeeding Rates and Hospital Breastfeeding Practices in Canada: A National Survey of Women. Birth. 2009, 36(2), 122-132.
2. Public Health Agency of Canada. What Women Say: The Maternity Experiences Survey of the Canadian Perinatal Surveillance System. Public Health Agency of Canada Report, 2009.
3. World Health Organization/UNICEF Protecting, Promoting and Supporting Breastfeeding: The special role of maternity services. A joint WHO/UNICEF Statement. Geneva: World Health Organization, 1989a.
4. World Health Organization/UNICEF. Ten Steps to Successful Breastfeeding. Geneva: Author, 1989b.
5. World Health Organization/UNICEF. Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. Breastfeeding in the 1990’s: Global initiative. WHO/UNICEF sponsored meeting, Florence, Italy, 1990.
Competing interests
Beverley Chalmers and Janusz Kaczorowski were both members of the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System. Beverley Chalmers was the Co-Chair of this group.